Payer Maximum Limits
Providers can limit the maximum Payer Contribution on some Contracts. The Provider can enter this maximum amount which is tracked according to the defined billing parameters before and after the maximum is reached.
Go to Patient > Contract > Additional Options > Additional Bill Info to access the Limit Maximum Payer Contribution per Period section in the Additional Bill Info window.
On this window, set billing limits per Patient at a Contract Level for the purpose of collecting revenue. Limits can be set per day, per week, per month, per year, and/or per lifetime of the Contract once this feature is enabled.
Once activated, the Provider can also designate which Contract to bill once the Limit is reached. As a required field When Limit is reached, send additional invoice to, Private Pay is selected by default. The Payer Adjustment Reason field is also required. The dropdown options are the same as the Payment Adjustment Reason Reference Table under the Fiscal category.
For example, the Limit Maximum Payer Contribution feature is selected and a $40 per day limit is set for this Patient for the selected Contract. With this setting, any amount exceeding the $40 limit for the day is invoiced to Private Pay as selected.
In this example, the total visit Amount is $60. Upon invoicing this visit, two invoices are created because the total Amount exceeds the $40 daily limit set for this Patient.
A Primary invoice is created for the full amount with a Partially Paid status. A Secondary invoice is created for Private Pay with the $20 balance with an Open status. The adjustment made for the Paid Amount can be verified from Patient Profile according to the check number generated.
The Invoice Details for the Secondary (Private Pay) invoice shows the balance with an Open status.
The following example demonstrates when both the Payer Discount and the Limit Payer Maximum features are combined.
The Payer Discount is set at 10% for the selected Contract. At the Patient level, the Limit Maximum Payer Contribution is set for $50 per day for the Contract. A visit is invoiced for a Total Amount of $100. In this case, two invoices are created. The Primary invoice is generated for the full amount with a 10% discount as an adjustment and a Partially Paid status.
A Secondary invoice is also generated to Private Pay for the balance of the exceeded Limit Max amount with an Open status.
Therefore, two adjustments are made for this combination; one for Discount Percentage and the other for the Limit Maximum with the selected Payment Adjustment Reason.
Providers can set multiple limits to allow for other billing rules to engage when a maximum limit has been reached; allowing one or more limit maximums per Contract, per Patient. Therefore, a Provider can set a daily amount limit, a monthly amount limit AND a yearly amount limit for the same Contract for the Patient.
Once limits are defined, select the applicable party to invoice from When limit is reached, send additional invoice to field as described in the previous section, Secondary Insurance Billing Enhancement.
To access this setting, go to the Patient’s Contract page under Patient > Contract. Click the Additional Options link for the applicable Contract. Select the Additional Bill Info option from the menu to access the window.
